Triplane Fractures

Introduction

A complex SH IV fracture pattern with components in all three planes
- triplane fractures may be 2, 3, or 4 part fractures
  - epiphysis fractured in sagittal plane (same as tillaux fracture)
  - physis separated in axial plane
  - metaphysis fractured in coronal plane
Epidemiology
- most common in ages 12-15 years
  - juvenile ankle physis ossifies in specific order, which leads to transitional fractures such as triplane and tillaux fractures
  - distal tibia physis order of ossification
    - central > medial > lateral
Mechanism
- usually result of ankle external rotation similar to tillaux fractures

Presentation

Symptoms
- ankle pain, inability to bear weight
Physical exam
- swelling, focal tenderness

Imaging

Radiographs
- AP radiograph shows Salter-Harris III
- lateral radiograph shows Salter-Harris II
CT scan
- usually required to delineate fracture pattern and access articular congruity
- fracture involvement seen in all 3 planes

Treatment

Nonoperative
- cast immobilization
  - indications
    - < 2 mm displacement
Operative
- CRPP vs ORIF
  - indications
    - > 2 mm displacement
  - techniques
    - epiphyseal screw placed parallel to physis
    - arthroscopic aided reduction can be used

Complications

Ankle pain and degeneration
- articular step-off >2mm

TAG

(OBQ06.160) Figures A and B show an AP and lateral radiographs of a 15-year old boy who injured his ankle after skateboarding. What is the mechanism of injury with this type of fracture? Topic

Review Topic

FIGURES: A

1. supination - adduction
2. external rotation
3. internal rotation
4. pronation - abduction
5. axial load

PREFERRED RESPONSE ▶

DISCUSSION: The fracture shown is a triplane fracture which is an external rotation injury that occurs in patients during early adolescence as described by Spiegel et al in a retrospective review of 237 cases. Kay et al has a nice review of pediatric ankle fractures. CT scans are usually obtained for these fractures and treatment depends on the amount of displacement.

REFERENCES:

1. Kay RM, Matthys GA. Pediatric ankle fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001 Jul-Aug;9(4):268-78. PMID:11476537 (Link to Abstract)

2. Spiegel PG, Cooperman DR, Laros GS. Epiphyseal fractures of the distal ends ofthe tibia and fibula. A retrospective study of two hundred and thirty-seven casesin children. J Bone Joint Surg Am. 1978 Dec;60(8):1046-50. PMID:721852 (Link to Abstract)

Question Authors:

Eric Shirley MD, Derek Moore,

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Kay RM, Matthys GA. Pediatric ankle fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001 Jul-Aug;9(4):268-78. PMID:11476537 (Link to Abstract)
Spiegel PG, Cooperman DR, Laros GS. Epiphyseal fractures of the distal ends ofthe tibia and fibula. A retrospective study of two hundred and thirty-seven casesin children. J Bone Joint Surg Am. 1978 Dec;60(8):1046-50. PMID:721852 (Link to Abstract)

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